Community CPR Classes

Date of Birth(Required)

Former/Maiden Name

Phone Number(Required)

Phone Type(Required)

Social Security Number(Required)

Email Address(Required)

County of Residence(Required)

How long have you lived at your current address?

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Emergency Contact Relationship(Required)

If you already have a visa, what type is it?

Race:

Choose One

Section II

High School Information

High School Name(Required)

City(Required)

State(Required)

Graduated (Year)

HiSET/GED Earned (Year)

Will Graduate (Year)

Section III: Colleges & Universities

Applicants MUST list all institutions of higher education.

School Name

Degree

Dates Attended

School Name

Degree

Dates Attended

School Name

Degree

Dates Attended

If you answered "Yes" to the above question, details must be provided to process application:

Section IV: Current Employment Information

Company Name

Date of Employment

Section V: Criminal Background

PLEASE NOTE! Any applicant who fails to list all criminal offenses on the college application shall be denied admission. Admitted students who are identified as having submitted a falsified application with respect to his or her criminal history, shall be expelled. Criminal history review requires application to be submitted at least 60 days prior to desired start term.

If you answered "Yes" to either of the above questions, details must be provided to process application:

Section VI: Tuberculosis Screening

Pursuant to Missouri State Statute 199.290, all institutions of higher education in Missouri shall implement a Tuberculosis Screening process.

Section VII: Admissions Policy

Three Rivers has an open-door admissions policy; welcoming applications for admission from any person who has a high school diploma, its equivalent, or is 18 years of age, and is able to benefit from a program may be admitted to Three Rivers as a curricular or non-curricular student. Three Rivers is an equal opportunity institution that commits itself to the policy that there will be no unlawful discrimination against any person because of race, color, religion, sexual orientation, disability, age, gender, or national origin. The College evaluates special cases for acceptance. Pursuant to Missouri State Statute 174.130, Three Rivers will not knowingly admit any aliens unlawfully present in the United States. Proof of legal residency may be required at the time of application.

Section VIII: Computer Network/Internet Acceptable Use Policy

Three Rivers requires that all students, faculty and staff fully comply with the Computer Network and Internet Acceptable Use Policy regarding their use of college computer equipment, local and wide-area networks and Internet services. By signing this admission application, you agree to comply with the terms of this policy and agree to review this policy each semester and agree with any changes or revisions.

Section IX: Notice of Federal Disclosure Information

Current federal law requires that eligible institutions participating in Title IV Financial Aid Programs disclose information to potential and currently enrolled students. A single-point access for required disclosure information can be found here. The Campus Security Report, issued in compliance with Title II of Public Law 101-542: Crime Awareness and Campus Security Act of 1990, is available on our website. Three Rivers College prohibits sexual harassment in any phase of its admission or in its education programs or activities. Student concerns or inquiries regarding Title IX should be directed to Title IX Co-Coordinator Ann Matthews at amatthews@trcc.edu.

Section X: Submission

I understand that Three Rivers will release my enrollment information to the National Student Clearinghouse and federal and state agencies. I further understand information on this form may be used by Three Rivers College , scholarship organizations and/or donors to determine scholarship eligibility (including but not limited to academic progress). I understand that falsification of information may prohibit me from receiving any scholarships. I hereby certify that to the best of my knowledge, the preceding information is true and complete without evasion or misrepresentation. I understand that if it is later found to be otherwise, it is sufficient cause for rejection or dismissal.

Name

This field is for validation purposes and should be left unchanged.

All classes must be paid for prior to attending. To pay over the phone, please call the Student Accounts Office at 573-840-9662. To pay in person, please visit the Student Accounts Office in Poplar Bluff, located in Suite 105 on the first floor of the Westover Administration Building.

Contact the Office of Student Accounts

Basic Life Support

CPR/First Aid Courses

Safe Sitter Courses

Non-Credit Application

Section II

Section III: Colleges & Universities

Section IV: Current Employment Information

Section V: Criminal Background

Section VI: Tuberculosis Screening

Section VII: Admissions Policy

Section VIII: Computer Network/Internet Acceptable Use Policy

Section IX: Notice of Federal Disclosure Information

Section X: Submission